Provider Demographics
NPI:1790823045
Name:WOIDA, DOUGLAS JEROME (MS PAS, PA-C)
Entity Type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:JEROME
Last Name:WOIDA
Suffix:
Gender:M
Credentials:MS PAS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
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Mailing Address - Street 1:1214 ORIOLE DR
Mailing Address - Street 2:
Mailing Address - City:OCONOMOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:53066-2373
Mailing Address - Country:US
Mailing Address - Phone:414-759-4111
Mailing Address - Fax:
Practice Address - Street 1:8500 W CAPITOL DR STE 100
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53222-1869
Practice Address - Country:US
Practice Address - Phone:414-431-5004
Practice Address - Fax:414-431-2959
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2019-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1865-23363AM0700X
WI1865363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1790823045Medicaid